An infectious optimism has infused the field of schizophrenia with the availability of the new “atypical” antipsychotics. However, an article by Geddes et al in this issue provides sobering evidence which questions this (p 1371).1 By pooling data from 52 controlled studies comparing atypical antipsychotics with the old typical antipsychotics in 12 000 patients, Geddes et al. failed to find any clinically significant evidence of superiority in efficacy, or for that matter tolerability, for atypical antipsychotics as a group, once the inappropriately high doses of the comparator were taken into account.

The results are even more sobering given the fact that most of these trials were conducted in patients who had already had a history of partial response to typical antipsychotics—thus having an inherent bias against the older typical antipsychotics. On the other hand, prescription data suggest that atypical antipsychotics account for nearly three out of four new prescriptions for antipsychotics in North America. So, how can we reconcile this large shift in prescribing practices (at least in North America) with the sobering evidence provided by Geddes et …

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